HomeMy WebLinkAboutMiscellaneous - 800 JOHNSON STREET 5/30/2018 (3) M'
TOWN OF NORT11 ANDOVER
OVER
commullity & Economic Development
HEALTH DEPARTMENT
20 Main Street.
NORT14 ANDOVER,1'ASS CUIUS1 11-S 01.845
978.688,9540.... Phone
978,688.9542--FAX
E-MAIL:licaltlidept@iiortlizindovei-ma.gov
iiortlazinctovei-ma.gov
E SITE:htt :P/%vww.nortliandovetinq,&v
SEPTIC PLAN SUBMITTAL
FORM
lJUN 2 3 201
Date of Submission: 0WN p NORTH ANDOVER
.. HEALTH DEPARTMENT
Site Location: Soo Sow" cam, `,
1
New Plans? Yes $275/Plan Check# ' (includes I" submission and one re-
review only)
Revised.Plans?Yes $125/Plan Checic#
Site Evaluation Forms Included? Yes No
Local Upgrade Form Included? Yes No
Telephone#:.__q3 !9-_SS,-_SSZ f ppZ ' "cpm V V:
E-mail: _ C �S •te✓ -_-_ ,20, ,0raN+ 1
homeowner
Name: q�'i 1 — a�►
10
i
OFFIC,'E iJ,SE ONLY
When the ssion is complete (including check):
> Date stamp plans and letter
S' Complete and attach Receipt
> :. Copy File; Forward to Consultant
> l nter on Log Sheet and Database
of, 4-
Town of North Andover
HEAL'in DEPARTMENT
CHECK DATE:
LOCATION:
H/O NAME:
CONTRACTOR NAME:
TgTe of Permit or License: (Check box)
0 Animal
0 Body Art Establishment
El Body Art Practitioner
0 Dunipster
0 Food Service Type,----
0 Funeral Directors
0 Massage Establishment
El Massage Practice
0 Offal(Septic)Hauler
0 Recreational Camp
0 Sun tanning
0 Swimming Pool
0 Tobacco
0 Trash/Solid Waste Hauler
0 Well Construction
SEPTIC Systems:
11 Septic-Soil resting
Septic-Design Approval �15
El Septic Disposal Works Construction(DWC)
IJ Septic Disposal Works Installers(DWI)
0 Title 5 Inspector
❑ Title 5 Report
0 Other. (Indicate).,—.----_
X0
kralth Agent Initialsi
White®Applicant Yellow-Health Pink..- Treasurer il